What is the cause of post-operative pain and hardening around the surgical site in a 76-year-old male following thrombectomy for Pulmonary Embolism (PE) removal?

From the Guidelines

The patient should resume taking Tylenol for pain management, and a chest CT should be ordered to rule out pneumonia, given the productive cough and chest X-ray findings. The patient's surgical site findings are consistent with normal post-procedural changes, with approximately 1 cm of hardening around the 0.5 cm wound on his left groin and tenderness when walking. According to the guidelines for postoperative pain management in non-traumatic emergency general surgery 1, postoperative pain must be recognized and treated as soon as possible and as best as possible in all patients. The patient's denial of fever, chills, shortness of breath, nausea, vomiting, or dizziness, and the absence of signs of infection or bleeding at the surgical site, suggest that the current pain management strategy should focus on resuming regular Tylenol.

The patient's laboratory results show normal CBC values with hemoglobin of 13.1 g/dL and hematocrit of 39.4%, and CMP shows slightly elevated glucose at 128 mg/dL and chloride at 112 mEq/L but is otherwise unremarkable. The patient is currently on Eliquis (apixaban), which is an important consideration given his recent thrombectomy and the potential for respiratory infection. The chest X-ray indicates an ill-defined density in the right lung with volume loss in the right hemithorax, raising concern for possible right lower lobe pneumonia.

Given the patient's recent procedure and age, it is essential to closely monitor his anticoagulation therapy with Eliquis and to further evaluate the chest X-ray findings with a chest CT to rule out pneumonia. The guidelines for the diagnosis and management of skin and soft-tissue infections 1 suggest that surgical site infections are rare during the first 48 hours after surgery, and fever during that period usually arises from non-infectious or unknown causes. However, the patient's productive cough and chest X-ray findings warrant further evaluation to rule out pneumonia.

Key considerations in the patient's management include:

• Resuming regular Tylenol for pain management
• Ordering a chest CT to rule out pneumonia
• Close monitoring of anticoagulation therapy with Eliquis
• Evaluation of the patient's surgical site for signs of infection or bleeding
• Consideration of the patient's recent procedure and age in the management of his condition.

From the Research

Patient Assessment

• The patient is a 76-year-old male presenting with post-operative pain after a thrombectomy for pulmonary embolism (PE) removal.
• He has a surgical wound of about 0.5cm on the left groin and reports pain when walking, with hardening on the incision site.
• The patient denies fever, chills, shortness of breath, nausea, vomiting, and dizziness, but reports some cough with mucus since the procedure.
• Physical assessment reveals about 1cm of hardening around the surgical site, with some tenderness but no signs of infection or bleeding.

Laboratory Results

• CBC shows RBC 4.32, hemoglobin 13.1, hematocrit 39.4.
• CMP glucose 128, Chloride 112, otherwise unremarkable.
• The patient is currently on Eliquis.

Chest X-ray Results

• The chest x-ray reads "III-defined density right lung with volume loss in the right hemithorax. Right lower lobe pneumonia cannot be excluded. Correlate with CT chest."

Possible Pneumonia Treatment

• According to the study by 2, ceftriaxone 1g daily is as safe and effective as other antibiotic regimens for community-acquired pneumonia.
• The study by 3 also suggests that 1g once daily of ceftriaxone is as effective as 2gm for the common causative organisms of community-acquired and nosocomial pneumonias.
• However, the study by 4 found that ceftriaxone use was associated with higher clinical failure of MSSA pneumonia compared with ceftaroline or ceftobiprole.
• The study by 5 found that ceftriaxone is not inferior to broad-spectrum antibiotic treatment for aspiration pneumonia and could contribute to reduction of medical costs.

SOAP Note

• Subjective: The patient reports post-operative pain, pain when walking, and hardening on the incision site.
• Objective: The patient has a surgical wound of about 0.5cm on the left groin, with about 1cm of hardening around the surgical site, and some tenderness but no signs of infection or bleeding.
• Assessment: The patient may have pneumonia, as suggested by the chest x-ray results, and may require antibiotic treatment.
• Plan: Further evaluation, such as a CT chest, is needed to confirm the diagnosis of pneumonia. Antibiotic treatment, such as ceftriaxone, may be considered based on the results of the evaluation and the patient's medical history, as supported by studies 2, 3, 5. However, the patient's specific condition and the potential for MSSA pneumonia should be taken into account, as noted in study 4.